412-828-1920

F: 412-828-8989

Som Gupta, DDS - Sumit Gupta, DDS
625 Allegheny River Blvd
Verona, PA 15147

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General Dentistry
Cosmetic Dentistry
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Comfort Dentistry
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First Name *

Last Name *

Phone Number *

Email Address *

Verify Email Address *

Date of Birth *

Date

E.g., 06/26/2017

Are you a new patient? *

Yes

How did you hear of us?

Is your family, friend or coworker a current patient? We’d love to have their name so we can thank them for referring you to us

How did you hear about our office?

Reason for your visit *

Dental Cleaning

Dental Emergency

Dentures or Implants

Cosmetic - teeth whitening, veneers, bonding, etc.

Filling

Crown

Extraction

Dental Consultation (Second opinion or Invisalign)

Other

Please provide a brief explanation of the reason for your visit

Are you experiencing pain, swelling, or bleeding? *

Yes

Where is the problem area located? *

Rate pain (1-10) *

On a scale of 1 to 10, please rate your level of pain with 1 being the least and 10 being the most.

Do you have insurance? *

Yes

Who is your dental insurance provider

Best day(s) for your appointment *

Monday

Tuesday

Wednesday

Thursday

Best time? *

Morning

Afternoon

No Preference

Specific Time

If a specific time is necessary, please indicate the time.

How do you prefer we contact you? *

Phone

Note: we do not accept appointment cancellations via email.

Do you require any special accommodations? *

Yes

Accommodations required

In order to request an appointment you must be 13 years of age or older. *

Yes, I am 13 years of age or older

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Verona Dental Care
625 Allegheny River Blvd
Verona, PA 15147
412-828-1920

Dental Professionals of Pennsylvania, PC

Verona Dental Care welcomes patients with disabilities. If you need an accommodation to receive dental services, we would be happy to provide one. Please contact us at 412-828-1920 to let us know how we may be of assistance.

Office Hours

Monday: 9:00 AM - 6:30 PM

Tuesday: 9:00 AM - 5:00 PM

Wednesday: 9:00 AM - 7:00 PM

Thursday: 9:00 AM - 5:00 PM

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